Discitis, unspecified, sacral and sacrococcygeal region
ICD-10 M46.48 is a billable code used to indicate a diagnosis of discitis, unspecified, sacral and sacrococcygeal region.
Discitis is an inflammatory condition affecting the intervertebral discs, characterized by pain and potential neurological deficits. In the sacral and sacrococcygeal region, discitis can arise from various etiologies, including bacterial infections, autoimmune disorders, or post-surgical complications. Patients may present with localized pain, fever, and neurological symptoms depending on the severity and extent of the inflammation. The sacral region is particularly vulnerable due to its anatomical position and the weight-bearing nature of the pelvis. Diagnosis typically involves imaging studies such as MRI or CT scans, which can reveal disc space narrowing, edema, or abscess formation. Treatment often includes antibiotics for infectious causes, anti-inflammatory medications, and in severe cases, surgical intervention may be necessary to decompress affected neural structures. Understanding the underlying causes, including associations with spondylopathies like ankylosing spondylitis or inflammatory spine conditions, is crucial for effective management.
Detailed surgical notes, imaging results, and post-operative assessments are essential.
Post-surgical discitis following spinal fusion or decompression procedures.
Documentation must clearly indicate the surgical history and any complications.
Comprehensive lab results, cultures, and response to treatment must be documented.
Discitis due to bacterial infections, particularly in immunocompromised patients.
Clear documentation of the infectious etiology and treatment regimen is critical.
Used in cases where surgical intervention is required for discitis.
Surgical notes must detail the procedure and rationale.
Orthopedic surgeons must document the need for surgery based on clinical findings.
Discitis can be caused by infections, autoimmune conditions, or post-surgical complications. Bacterial infections are the most common infectious cause.
